New analysis reveals lack of diversity in surgical leadership in the U.S.

Reviewed by Danielle Ellis, B.Sc.Oct 11 2023

Women and those from racial and ethnic groups underrepresented in medicine (URiM) not only occupy few leadership roles in surgical departments but also tend to be clustered into certain leadership roles, according to a new analysis led by researchers from the Perelman School of Medicine at the University of Pennsylvania. These clusters of roles include vice chairs of diversity, equity, and inclusion (DEI) or wellness, where the promotion path to department chair is unclear. The report was published today in JAMA Surgery and led by Oluwadamilola "Lola" Fayanju, MD, MA, MPHS, the Helen O. Dickens Presidential Associate Professor and chief of the Breast Surgery Division, who joined Penn in 2021 and has since become the first Black division chief in the history of Penn's department of Surgery.

The field of surgery has long been dominated by white men, who account for nearly half (46.2 percent) of practicing general surgeons, according to the Association of American Medical Colleges (AAMC). While recruiting a diverse pipeline of physicians has become a priority in recent decades, whether these efforts will translate into diversity at leadership levels will take time to realize. Currently, women represent 14.1 percent of surgery department chairs, and represent only 8.9 percent of surgery department leaders at academic medical centers in the United States.

A longtime metric for success of diversity in medicine is how many women and people from certain backgrounds are department chairs, which represents the pinnacle of achievement in academic medicine. For this study, we wanted to look at multiple levels of leadership, a proxy for trajectory through leadership, across all surgical specialties and ask whether the field is looking at the right pipelines and endpoints to achieve a level of diversity in physician leadership that better mirrors the diversity of our patient population in the U.S."

Oluwadamilola "Lola" Fayanju, MD, MA, MPHS, the Helen O. Dickens Presidential Associate Professor

The study included data from publicly accessible websites of 165 departments of surgery, neurosurgery, obstetrics and gynecology (OBGYN), ophthalmology, orthopedics, and otolaryngology in medical schools and affiliated hospitals in the U.S. and Puerto Rico. The researchers used methodology previously developed and used in other published studies to identify demographics of more than 2,000 surgery leaders based on the publicly available profile, biography, and visual information found online. To overcome and address the limitations of this approach, the team used a multi-coder system with a diverse team of reviewers.

In academic medicine – where medical schools are associated with hospitals that provide patient care – department chairs are physicians or researchers who also have an administrative role to lead a large group of faculty members with the same expertise, such as surgery or medicine. They may be supported by a leadership team that includes vice chairs, who generally do not have direct reports, and division chiefs, who function in roles similar to the chair, in that they oversee staff, budgets, and programs, for a smaller, further specialized group of faculty members, such as cardiovascular surgery or hematology-oncology. In recent years, with greater attention on racial justice and work-life balance, additional vice chair roles that support newly prioritized focus areas, such as DEI or faculty development, have become more common.

Fayanju and colleagues found that women were more likely to be in a surgery vice chair role (31.6 percent female vs. 68.4 percent male) than in a surgery chair (14.1 percent female vs. 85.9 percent male) or division chief role (12.9 percent female vs. 87.1 percent male). Even in OBGYN, where most physicians are women, they only account for 32.9 percent of department chairs. Vice chairs of DEI were majority female (64.5 percent) and URiM individuals (51.6 percent), while vice chairs of faculty development were split evenly between men and women, with only 17.9 percent URiM individuals. Breast/Endocrine surgery was the only specialty where women held the majority (63.6 percent) of division chief roles. No URiM individuals held vice chair of research roles.

The demographics of surgery division chiefs most closely resembled the current demographics of surgery department chairs, but women and those from underrepresented backgrounds were less likely to be in these roles. The authors note that it's unclear if this is a lag effect of recruitment efforts and newly created leadership roles or if women and URiM individuals are being elevated to leadership roles that don't necessarily have a path for promotion to chair.

The authors suggest the findings should also prompt academic medicine leaders to rethink traditional paths and metrics for promotion, such as grant funding, publications, and other measurements that may not relate to leadership ability.

"We know that other fields are looking at how to promote people and recognize their excellence without appointing them to lead others simply because it's the next step," Fayanju said. "We should think about how different opportunities for career advancement can be promoted and we should also equip diverse people for leadership, so that everyone has the opportunity to put themselves forward for leadership roles that align with their interests and career goals."

The co-first authors were Yoshiko Iwai, MS, of The University of North Carolina at Chapel Hill School of Medicine, and Alice Yunzi L. Yu, MD, of the Northwestern University Feinberg School of Medicine. The work was supported by the National Institutes of Health (7K08CA241390, P30CA014236), the Duke Cancer Institute, and the Duke Global Health Institute.